Peripheral Neuropathy, Balance and Falling

Can you explain how skin affects balance?

It is commonly known that loss of joint range of motion in the foot, ankle, hip and spine can impact one’s balance1-3, especially when trying to walk across an uneven parking lot, the backyard, down a gravel driveway or climbing up the stairs. But how can the skin on your lower leg impact balance? And what if you have been told that you have “peripheral neuropathy” …a symptom and a disease process where sensory nerves (peripheral nervous system) transmit information from the skin and muscles in your legs and arms, to the spinal cord and brain (central nervous system), have been damaged. Radiation/chemotherapy, poor blood supply and long-standing high blood sugar levels (diabetes), vitamin deficiency, history of trauma or a chronic condition of cellulitis, a deep infection of the skin that when healed, changes the texture of the skin, all alter the pathway of sensing touch and the feeling of our skin.

“I can’t feel my feet or below my knees” is, unfortunately, a common complaint and symptom reported by many who are given the diagnosis of peripheral neuropathy. Decreased sensation, numbness, burning, and shooting pain can also be present in one or both legs or even in certain areas of one foot or lower leg. For some, this diagnosis and ongoing feeling may seem hopeless and scary. Many people do not know that peripheral nerves connecting our legs and arms to the spinal cord and brain have the capacity to regenerate. It is not a fast process, 1 mm/day and can take up to 3-4 months depending upon the extent of the damage and if certain conditions are met4: nutrition (vitamins and avoidance of certain foods), nor

mal blood sugar levels and the absence of infection are the basics. And yet for some people, nerve regeneration is not possible because they have let their condition go too long or the damage has been too great. The sensations in the lower leg can be progressively distorted from the peripheral nerve damage and can cause a person to mis-step and even fall. Falling then becomes another condition that many fear. Not just in the US, but globally, falls are a major public health problem and the financial costs from fall related injuries are significant.5

The anatomy of skin and sensation: somatosensory receptors

To help reduce the risk of fall for a person who has peripheral neuropathy we need a brief understanding of the specialized skin cells or sensory receptors that receive information from the environment and transmit that information along a predictable pathway to the spinal cord and brain. The sensory neuron is not just one nerve but many millions of nerves “packaged up” like a box of uncooked thin spaghetti noodles. Each “box” of sensory neurons is dedicated to extracting highly specific and localized information from your contact with the environment. At the end of each “spaghetti noodle”, the sensory neuron is connected to four categories of tiny specialized receptors or nerve endings: mechanoceptors (detect mechanical sensations or differences in pressure), chemoreceptors (detect chemicals that are responsible for pain and itching), photoreceptors (detect light), and thermoreceptors (detect changes in skin and blood temperature).

Mechanoreceptors play a role in keeping us upright against gravity by recognizing and feeling touch, vibration, pressure and tension in the skin. Imbedded within the skin are six different kinds of mechanoreceptors that sense changes in the skin. Normally, these mechanoreceptors work together sending their unique information along their dedicated sensory neuron to the spinal cord and then to the brain. The brain receives the message that something is touching the skin at a precise location, intensity and duration of the specific mechanoreceptor that sent the message. The brain can then make informed decisions about what should happen next, such as, pick up your foot, move away from cold, swat that fly, don’t stand on the snowy concrete in your bare feet, press down with your foot, etc.

The power of the brain lies in the parallel action of millions of cells, each doing something different; to understand the brain we need to understand how its tasks are organized and how individual neurons carry out those tasks.6 – Esther P. Gardner

Types of Skin Mechanoreceptors7:

Located in the superficial or shallow layers of skin (epidermis)

Merkel’s disks: detect light touch or pressure that allows the location of touch to be pinpointed, sense rough and change in textures

Pacinian corpuscles: detect deep and transient pressure; high frequency or sudden changes in vibration, also found in the bone periosteum and joint capsules

Located all over the body: skin, muscles, fascia, joints, blood vessels, bones, and internal organs.

Nociceptors (means sensitive to harmful or painful stimuli): detect signals from damaged tissue or extreme distortion that threatens to damage tissue; their signals reach pain centers in the brain.

In peripheral neuropathy, the mechanoreceptors located in epidermis or the top layer of skin are not only less in number, but they are no longer strong, thick cables.8 It’s like the “spaghetti noodle box” has been opened and scattered on the floor. The ability to sense light pressure and find touch is markedly diminished or absent. It also takes a lot more stimulus or higher intensity to sense changes in temperature and vibration. The presence of excess glucose or sugar in the blood and chronic inflammation due to cellulitis or diabetes causes the mechanoreceptors to die and the ends of the nerves retract back down into the dermis.9

The brain and balance

In peripheral neuropathy, the mechanoreceptors in the top layer of skin that allow you to sense and discriminate light touch, texture, and temperature are gone and may not be coming back. When this happens, the brain and spinal cord do not receive accurate information about the lower leg and will not signal the muscles in the trunk, hip and lower leg to pick up the foot when there is an object on the floor, a step to clear or navigate uneven ground. The brain’s image of the foot may be interpreted as small thick tree stump and the normal reflexes, that should occur in the spinal cord that keep you from falling, will not be stimulated. The equilibrium reflex is out of your conscious control and is evident when you see someone quickly pick up their foot and place it down again as the brain’s attempt to abort a fall.

The foot feels the foot when it feels the ground. -Buddha

If you have peripheral neuropathy or you want to help a person whose sensation is markedly distorted, think DEEP PRESSURE. Understand that deep pressure DOES NOT mean “deep tissue massage”. In order to stimulate the mechanoreceptors located in the dermis of the foot and in the joints of the foot and ankle, one must apply a gradual, non-painful and sustained pressure for at least 3 seconds followed by a complete release of the pressure. This application of deep pressure is not done randomly. Using a skeletal picture of the foot and lower leg, one must “map out” the toes, foot and lower leg. In other words, the pressure applied feels like a firm, but non-painful squeeze of the skin and underlying tissue into the bone. In the brain, stimulation of the deeper layer of mechanoreceptors can transform the image of the foot from a tree stump into foot that allow the possibility of natural reflexes be activated that could keep you safe if you get off balance.

GAIT: Activating Your Human Potential

In somatic education, we use a variety of movement-based platforms that activate these deeper mechanoreceptors. In addition to the above exercise, have a look at these two videos. One is using a movement process from the Bones for Life curriculum used in our Gait for Human Potential workshops. Lying on the back one can use the foot on the wall to stimulate the deeper mechanoreceptors of the foot, leg and trunk. The same movement process can also be adapted in sitting.

The second video is a very clever way to restore the normal joint movement patterns of the trunk, hip, knee, and foot. Most people don’t know that foot numbness and poor self-image of the foot translates to poor or dysfunctional movement patterns in the hip and trunk. In this video, the stroking of the leg with the hand is not intended to re-map the foot or lower leg. But it does offer the possibility of restoring the coordinated movement patterns of the trunk and hip. Demonstrated while sitting of the floor, this same movement, with awareness can also be done in sitting and then advanced to standing.

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Carol is a physical therapist, a co-creator of Integral Human GaitSM theory, a certified Feldenkrais practitioner, and a Senior Trainer in Movement Intelligence. Focus, Align, Teach and Inspire! These qualities not only describe her work, they describe her presence. She is passionate when it comes to reconnecting learning with human function and health. Carol is in private practice at MontgomerySomatics.com in Columbus, Indiana.

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I was stretched and challenged by the 'Bones' training. Cynthia’s teaching style is humorous and encouraging. Her presentations were very professional yet casual and accessible. This different type of learning thru physical experience is new for me. I feel awkward and like a child, only not so agile. Upon returning home, I was sitting on Continue Reading

Yvonne Kress

I greatly appreciate the opportunity to learn with you Cynthia. Your clarity and comfort in teaching is amazing. The work and passion you have put into this process shines through. Ruthy Alon and her work is truly remarkable.

Suzanne MoweryPhysical Therapist

I love the program and must tell you that after the workshop a longtime student told me that he'd never seen my posture and walking look so good. Thank you, Cynthia again for your clarity, your vision and your hard work. I look forward to our next segment, to teaching classes and being your mentee.

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The feeling Bones for Life awakens in me gives me hope. I have also been using some of the exercises with the little frail COPD people I serve. It is amazing how gentle and effective it can be. As I guide them to pay attention, they notice how much it opens their breath.

Susy BogeOccupational Therapist OTR/L

Cynthia really brought the group along. She is supportive, taking time to answer question and also helping me to expand my thinking not just giving away the answers. I feel blessed to have had this chance to study with her and excited about the Bones for Life path ahead.

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Carol is an incredible teacher; timing and pace are artful. You keep on learning and discovering and the joy you experience emanates.

Linda Richard

Carol, I love who you are and all that you shared with all of us. You are so present, engaged, passionate and knowledgeable. Your presence shines and for me is an inspiration to teach this work to help others too.

Penny Neu

Carol’s compassion, gentleness, knowledge and awareness were very much appreciated and made the whole experience of learning wonderful! I experienced a new way of myself. Instead of trying to change—fix or let go—I am more curious to experience and see what is already there, allowing my natural intelligence for freedom and alignment to be.

Carol Wirtz

I am so grateful for the time spent with you last weekend! You made it possible for me to be reacquainted with this (almost) 70 year old body in a most gratifying way. Learning did take place in a most gentle, logical order that has given me much optimism about the present and the future. Continue Reading

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Thanks so much for another amazing workshop! Always useful, always illuminating. Cynthia and Carol are brilliant educators.

Feldenkrais®, Feldenkrais Method®, Awareness Through Movement® are service marks of and Guild Certified Feldenkrais Practitionercm (tiny text for the cm, just like you find with the ™ ) a certification mark of the Feldenkrais Guild® of North America.